Provider Demographics
NPI:1376578658
Name:BUCKNILL, DIANE WALKER (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:WALKER
Last Name:BUCKNILL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SENIOR HEALTH UNIT, CP2 502
Mailing Address - Street 2:165 CAMBRIDGE ST
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-726-4600
Mailing Address - Fax:
Practice Address - Street 1:SENIOR HEALTH UNIT, CP2 502
Practice Address - Street 2:165 CAMBRIDGE ST
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123257363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41547Medicare UPIN
MANP4828Medicare ID - Type Unspecified